Skin failure and pressure injuries

Risk factors, symptoms, and signs associated with skin changes at the end of life include loss of appetite, weight loss, cachexia and wasting, low haemoglobin, and dehydration.

Physiological changes that occur as part of the dying process may affect the skin and soft tissues and be observable as changes in skin colour, elasticity, or integrity or as symptoms such as localised pain.

Pruritis (skin itchiness) may also develop as an adverse reaction to opioid medicines, or as a symptom of cancer or end stage liver or kidney disease.

Ageing, smoking, diabetes, peripheral neuropathy, COPD, kidney disease, anaemia and other vascular conditions all lead to decreased circulation, increasing risk for skin breakdown. In advanced disease this can lead to skin damage and wounds including:

• pressure ulcers
• moisture lesions
• skin tears
• dry irritated skin
• malignant fungating wounds
• fistulae
• blistering skin conditions.

Care of the skin is primarily prevention of injury and monitoring for changes that accompany advanced illness. Management of a skin issue will depend on what it is and the likelihood for it to heal.

Pressure ulcers can be caused by lying or sitting for long periods of time without changing position. In palliative care patients, pressure ulcers can develop very easily and quickly and once present, they are difficult to heal. It is important to understand that in the terminal phase of illness, despite the best care, it may be difficult to prevent the development of a pressure ulcer.

Nurses should regularly check the skin when the following risk factors associated with skin breakdown and pressure ulceration are present:

• muscle weakness and inability to move independently
• loss of loss of appetite, weight loss, cachexia (severe wasting), dehydration
• dementia
• loss of skin integrity due to incontinence, skin tears, body fluids/exudate, and equipment and devices, such as intravenous cannulas, lifting or standing equipment
• reduced immunity that increases the risk of infection
• a history of pressure ulcers
• diabetes, heavy smoker or circulation problems
• loss of sensation in the skin due to illness or medication.

When assessing skin look for:

• a discoloured area that does not fade when gentle pressure is applied – either press the side of a clear glass firmly against the skin to see the colour of the skin or press gently with a finger for three seconds then release
• red patches for people with white skin and purple or blue patches for people with dark skin
• an area of skin that is a different temperature or feels harder or softer than the surrounding skin
• swelling, pain, itchiness (pruritis).

Pay particular attention to areas prone to skin breakdown due to pressure such as the sacrum, coccyx, ischium, trochanters, scapula, occiput, heels, elbows and ears.

When assessing pressure ulcers look for:

• pain
• unpleasant odour
• putrid discharge.

The Braden Scale, Waterlow Scale or Norton Scale may be used to assess risk for pressure injury. These scales have been shown to have adequate to good predictive validity (the degree to which the test accurately predicts a measurable outcome) but most research has not been conducted in a palliative care context.

It is important to determine the impact of the wound on the person and if the wound has the potential to heal.

Management includes prevention, and treatment to heal or treatment to limit the impact on the person’s quality of life.

Use the concerns identified by the person (e.g. pain, mobility, aesthetics) to guide the way you manage skin and wound care.

Nurses can care for the skin and prevent skin wounds through:

• good hand hygiene with short nails and no rings
• careful positioning to avoid friction and shearing forces, bumps, and scratches
• regular turning and repositioning with attention to the person’s comfort and preference
• limiting the person’s lateral rotation to 30 degrees from the supine or prone position to avoid direct loading of the greater trochanter – see illustration
• avoiding vigorous skin contact or rubbing
• appropriate continence management program
• cleaning skin with pH neutral skin cleanser and drying gently and thoroughly
• protecting skin with water-based skin emollients or barrier products
• providing appropriate pressure-relieving equipment (e.g. heel protectors, cushions, pressure-relieving mattress, positioners to offload pressure by suspending, elevating, or changing position of the body area) – remember, this does not replace turning schedules
• ensuring adequate nutrition and fluid intake (as appropriate)
• good bedmaking skills – critical if someone is bedridden.

Management of pressure ulcers includes the preventive measures above and

• explaining the treatment options and treatment goals to the person, family, and carers
• covering the area or wound with a suitable dressing
• managing pain with regular analgesia and pain relief prior to wound care
• choosing wound cleansers and dressings that reduce the pain and require less frequent changing, and wound cleansers that are warm rather than room temperature
• referral to wound care specialist for complex wounds or when symptoms are not well controlled
• weighing the benefits of frequent repositioning against the potential for unnecessary pain especially when the person is close to death
• complementary therapies and emotional support – people may get comfort from music, touch, relaxation, distraction, or a therapy animal.

Practical considerations when attending to pressure ulcers and wounds include:

• When a KTU or TB-TTI is identified, a focus on managing symptoms and comfort instead of closing or healing the ulcer is appropriate. Part of this care will be informing the family and carers that this type of skin injury indicates that the person is in the terminal phase of life and preparing them for the prospect that death is imminent.
• For wounds not expected to heal, choose a dressing that provides the most comfort and minimises odour. It may be necessary to try a number of different dressings to find one that meets the needs of the person and carer and does not exacerbate symptoms.
• Reducing the frequency of dressing changes to optimise wound care as much as possible while minimising distress associated with dressing changes. Ensure dressings are well moistened before gentle removal, to prevent trauma, bleeding, and pain; non-adherent dressings are preferred.
• Acknowledge any concerns or wishes of the person and their family and ask what concerns them most. The top priority is the person’s comfort and dignity.
• Family and carers may be able to help the person concerned with the appearance of wounds or ulcers (favourite clothes or make up might help to divert attention).
• Severe or persistent pruritus (itch) is less common but can cause significant distress and poor quality of life. If dry skin is the cause, nonfragrant topical emollients, especially after bathing, can help. Topical therapies (topical anaesthetic, antihistamine, or corticosteroid) are generally preferred especially when pruritus is mild, intermittent, or localised.